Endoscopic full-thickness resection of esophagogastric junction gastrointestinal stromal tumor assisted by laparoscopy after neoadjuvant therapy

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the digestive tract [1]. Surgery is the only potentially curative therapy. However, some tumors are locally advanced, and therefore R0 resection cannot be guaranteed. In this situation, imatinib can allow organ-preserving surgery and optimal oncological outcome [2] [3] [4] [5].

GISTs located at the esophagogastric junction (EGJ) are challenging because wedge resection is difficult to achieve, and gastrectomy and/or esophagectomy are associated with morbidity and mortality. Consequently, endoscopic resection could be an ideal alternative to surgery, with comparable oncological outcomes.

We present the case of an 82-year-old woman with a 1-month history of progressive dysphagia. An upper endoscopy showed a 6-cm pedunculated polypoid lesion at the EGJ, with a short and wide pedicle that protruded into the gastric fundus. The biopsy demonstrated a high-risk GIST with 20 mitoses per 50 high-power fields (HPF). Abdominal double-contrast radiography and computed tomography (CT) scan ruled out metastasis ([Fig. 1]). It was decided to treat the tumor with imatinib to decrease its size. A 6-month course of therapy was started.

Fig. 1 Gastrointestinal stromal tumor at the esophagogastric junction. a Double-contrast radiography. b Computed tomography.

CT scans performed at 1 week, and at 2 and 4 months showed optimal response to treatment, with a decrease in size from 6.5 cm to 2.7 cm ([Fig. 2]). Because of the patient’s co-morbidities, an endoscopic resection with laparoscopic support was then performed ([Fig. 3]). Briefly, the laparoscopic surgeon released the upper part of the lesser and greater curvature of the stomach for better mobilization ([Fig. 4]). The endoscopist completed the en bloc resection using a diathermic snare with the support of the laparoscopic surgeon, who pushed the lesion inside the snare, avoiding perforation ([Video 1]). After resection, seroserosal stitches were applied by the laparoscopic surgeon to reinforce the resected area ([Fig. 5]).

Fig. 2 Computed tomography with perfusion. a Before neoadjuvant therapy with imatinib. b 1 week after treatment with imatinib. c 2 months after treatment. d 4 months after treatment. The size of the lesion decreased progressively.

Fig. 3 Intraoperative endoscopic view in retroversion of the lesion at the esophagogastric junction.

Fig. 4 Laparoscopic view showing the complete liberation of the upper part of the stomach for optimal mobilization of the esophagogastric junction.

The full-thickness endoscopic resection was performed using a diathermic snare with the support of the laparoscopic surgeon, who assisted the endoscopist by pushing the lesion inside the snare.

Fig. 5 Laparoscopic stitches were placed in the resected area to reinforce the tissue and to prevent delayed perforation.

The final histology showed a GIST of 3.8 cm with 1 mitosis per 50 HPF (low-risk lesion). After 6 months of follow-up, there was no recurrence.

Endoscopy_UCTN_Code_TTT_1AO_2AG

 

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Competing interests: None

• References

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